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elcome Parents:

We are so glad to have your children be part of our new program. We arelooking forward to watching your children succeed and make new friends inour innovative socialization program.

e are forming a partnership with you for the benefit of your child. We willalways be available to answer your questions or concerns.

Best Regards,

Piera & Chris

Piera Bacolo (718) 605-6930Chris Caruso (718) 874-6109

ame of child: _________________________________________________

Date of birth: _________________

School child attends: _____________________________________________________

Parent’s name: _________________________________________________

ddress: ______________________________________________________

Phone Numbers

Home: _______________________________

ork: _______________________________

Cell: _______________________________

Email address: ________________________________________

How did you hear about us? _____________________________________

Please list any allergies child may have:

______________________________________________

Information Sheet

When was he/she diagnosed and what is the diagnosis?

__________________________________________

Is he/she on any medication?

_____________________________________________

What are his/her verbal capabilities? _______________________________________ How well does he/she follow verbal prompts/instructions? ___________________________________ ____________________________________________________________________________________

1. _________________________________________________ 2. ________________________________________________ 3. ________________________________________________

Information about your child:

Please list any likes or dislikes your child may have:

In the box below, please tell us a little about your child: